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Open Access Original
Article DOI: 10.7759/cureus.24681
Nutritional Risk Screening in Hospitalized Adults
Using the Malnutrition Universal Screening Tool
at a Tertiary Care Hospital in South India
Review began 04/15/2022
Review ended 04/25/2022
1 1 1
Arankesh Mahadevan , Hariharan Eswaran , Meenakshi Sundari
Published 05/02/2022
© Copyright 2022
1. Internal Medicine, SRM (Sri Ramaswamy Memorial) Medical College Hospital & Research Centre, Kattankulathur,
Mahadevan et al. This is an open access
IND
article distributed under the terms of the
Creative Commons Attribution License CC-
BY 4.0., which permits unrestricted use,
Corresponding author: Arankesh Mahadevan, arankeshmahadevan@gmail.com
distribution, and reproduction in any
medium, provided the original author and
source are credited.
Abstract
Background and objectives
Malnutrition is still widely prevalent in India. Various nutritional screening tools have been developed to
screen for nutritional risk status but no one tool is considered the best. The Malnutrition Universal
Screening Tool (MUST) is accepted by the European Society for Clinical Nutrition and Metabolism and
validated for use in hospitalized adults. Hence, it was used in this study to estimate the prevalence of
malnutrition in hospitalized adults and its association with socioeconomic inequality.
Methods
A sample of randomly selected 358 ambulatory hospitalized patients above 18 years of age was used in the
study. Data pertaining to demography, socioeconomic status, medical history, and MUST were collected
using a structured questionnaire. The height and weight of the patients were measured, and their BMI was
determined. The patients were classified into five socioeconomic classes and their MUST scores were
determined.
Results
Statistically significant (P < 0.05) increasing trend was observed in the height, weight, and BMI of patients
with increasing socioeconomic status. Diabetes mellitus (39%) followed by hypertension (30%) were the
predominant comorbid conditions. According to MUST, the overall prevalence of medium and high risk of
malnutrition was 11% and 24%, respectively, and the socioeconomic class that was most impacted was Class
4 (1,130-2,259 INR per capita monthly income).
Interpretation and conclusions
Socioeconomic status influences the prevalence of malnutrition, comorbid conditions, and the
anthropometric measurements of admitted patients. The prevalence of nutritional risk status irrespective of
sex was found to be 34.91% (24.3% in males and 10.61% in women) in the study.
Categories: Epidemiology/Public Health, Nutrition
Keywords: body mass index, hospitalized patients, nutritional risk screening, socioeconomic status, malnutrition
universal screening tool
Introduction
Malnutrition is a condition in which the body’s nutritional requirements are unmet due to
underconsumption or impaired absorption [1]. According to the Global Nutritional Report 2020, India is
among 88 countries that are expected to miss all the global nutritional targets by 2025 set by the World
Health Assembly [2]. The magnitude of malnutrition in India is underreported and is further complicated by
a lack of consensus on diagnostic criteria for application in clinical settings. A study by the NCD Risk Factor
Collaboration (NCD-RisC) reports that although the prevalence of moderate and severe underweight has
decreased worldwide from 9·2% in 1975 to 8·4% in 2016 in girls and from 14·8% in 1975 to 12·4% in 2016 in
boys, the prevalence of moderate and severe underweight was still highest in India, at 22·7% among girls
and 30·7% among boys in the age group of 5 to 19 years [3]. Intervention to improve the current situation of
poor nutritional status in the country requires a quick and accurate diagnosis of malnutrition. The presence
of various nutritional screening tools for the diagnosis of at nutritional risk status, both validated and not
validated, produce varying results. There is no consensus on a single ‘best’ tool and the use of different tools
in different studies hinders the ability to make conclusions [4]. The European Society for Clinical Nutrition
and Metabolism (ESPEN) suggests the use of the Malnutrition Universal Screening Tool (MUST), which is a
validated screening tool to identify adults who are malnourished or at risk of malnutrition (undernutrition)
[5,6].
How to cite this article
Mahadevan A, Eswaran H, Sundari M (May 02, 2022) Nutritional Risk Screening in Hospitalized Adults Using the Malnutrition Universal Screening
Tool at a Tertiary Care Hospital in South India. Cureus 14(5): e24681. DOI 10.7759/cureus.24681
There exists significant socioeconomic inequality in malnutrition; studies have shown an inverse
relationship between malnutrition and the economic development of local districts of India. A study
analyzing India’s National Health Family Survey (2005-2006) concluded that higher wealth is associated
with a lower likelihood of being underweight across all sub-populations [7,8]. Various scales have been
developed in India to assess the socioeconomic status of populations, both urban and rural. The BG Prasad
scale is used to estimate the socioeconomic status of individuals in both urban and rural settings using just
per-capita monthly income and is revised yearly based on the consumer price index (CPI) updated by the
Government of India [9,10]. The presence of comorbid conditions, viz., diabetes mellitus, hypertension,
chronic kidney disease, etc., significantly worsens malnutrition, the exact reasons being multifactorial. The
situation can be further aggravated by hospitalization as patients often receive less than optimal nutrition
during their stay. Previous studies have associated a higher prevalence of malnutrition in patients with a
higher Charlson Comorbidity Index [11]. Hence, this study was designed to evaluate the prevalence of
malnutrition and its association with socioeconomic inequality in the presence or absence of comorbid
conditions using a validated nutritional screening tool at a tertiary care hospital in Chengalpet district,
Tamil Nadu, India.
Materials And Methods
A cross-sectional study was undertaken with patients admitted to SRM Medical College Hospital and
Research Centre, Kattankulathur, Tamil Nadu, India. The study was approved by the institutional ethics
committee of the SRM Medical College Hospital & Research Centre, Kattankulathur, Tamil Nadu, India
(approval number: 2901/IEC/2021). Voluntary written informed consent was taken from all the patients
admitted for the study.
Of the total patients admitted to the hospital between August 2021 to December 2021, 358 patients were
randomly selected for the study. This sample size of 358 was determined using the sample size formula
usually used for qualitative variables in cross-sectional studies or cross-sectional surveys for an expected
prevalence of 37.1% [12,13]. Sample Size (n) = .
The inclusion criteria adopted for the selection of patients for this study were all patients above 18 years of
age who were admitted and from whom consent was obtained. Patients who were not ambulatory, were
pregnant, and/or who did not provide consent for data collection were excluded from the study.
A pilot-tested structured questionnaire was used to document the data from the selected patients by the
research team at the patient’s bedside. The questionnaire included demographic data (age and sex),
socioeconomic status information (family income, number of family members), medical condition of the
patient (primary diagnosis and comorbid conditions), and data about MUST that included two important
criteria: history of unplanned weight loss in the past six months, which was classified as > 10%, 10 to 5%, <
5% body weight, and acute illness of patient or patient having no nutritional intake for > 5 days.
In addition, anthropometric data from the patients were collected as per CDC, 2020. Height was measured
using a two-meter stadiometer and measurements made up to the nearest 0.1cm, with patients standing
barefoot, back straight, ankle, buttocks, shoulders, occiput touching stadiometer, and Frankfort horizontal
plane parallel to floor and height was expressed in meters (m). Weight was measured using a standard
weighing scale to the nearest 0.01kg with patients wearing as minimal clothing as possible and weight was
expressed in kilograms (kg). From the measurements of height and weight, BMI (kg/m2) was calculated [14].
From the data, patients were divided into socioeconomic groups using the updated 2020 BG Prasad
Socioeconomic Status Classification as it is applicable for both rural and urban populations in India [9].
MUST score was calculated and patients were classified as low risk (score = 0), medium risk (score = 1), and
high risk (score >= 2). Medium risk and high risk patients were categorized as at nutritional risk [6].
The data were analyzed with analysis of variance (ANOVA) and linear regression analysis using IBM SPSS
Statistics for Windows, Version 28.0 (Released 2021; IBM Corp., Armonk, New York, United States). The
critical difference between the groups was analyzed using Duncan’s multiple range tests and was presented
in tables indicated by suitable alphabetical superscripts.
Results
The study involved a total of 358 patients, of which 238 (66.5%) were male and 120 (33.5%) were
females. The details of the selected patients for the study are presented in Table 1.
2022 Mahadevan et al. Cureus 14(5): e24681. DOI 10.7759/cureus.24681 2 of 8
Male Female Total
1. Number of patients 238 (66%) 120 (34%) 358
2. Age (Years) 51 ± 15 45 ± 12 49 ± 14
3. Socioeconomic class (income per capita/month)
Class 1 ( > 7,533 INR) 35 (10%) 3 (1%) 33 (11%)
Class 2 (3,766-7,532 INR) 68 (19%) 27 (8%) 95 (27%)
Class 3 (2,260-3,765 INR) 63 (18%) 54 (15%) 117 (33%)
Class 4 (1,130-2,259 INR) 51 (14%) 23 (7%) 74 (21%)
Class 5 ( < 1,130 INR) 21 (6%) 13 (3%) 34 (9%)
4. Department of admission
Medical departments 135 (38%) 90 (25%) 225 (63%)
Surgical departments 103 (29%) 30 (8%) 133 (37%)
5. Co-morbidities
Diabetes mellitus 90 (25%) 49 (14%) 139 (39%)
Hypertension 79 (22%) 29 (8%) 108 (30%)
Cardiovascular diseases 37 (10%) 8 (3%) 45 (13%)
Thyroid diseases 10 (3%) 25 (7%) 35 (10%)
6. Nutritional characteristics
Height (m) 1.637 ± 0.070 1.526 ± 0.068 1.600 ± 0.087
Weight (Kg) 66.367 ± 14.716 56.881 ± 12.769 63.188 ± 14.772
2
24.395 ± 5.327 24.455± 5.443 24.415 ± 5.359
Body mass index (Kg/m )
TABLE 1: Details of the patients selected for the study (Mean ± SE)
The predominant socioeconomic class amongst males was Class 2 (19%), in females it was Class 3 (15%), and
irrespective of sex it was Class 3 (33%). The majority of patients were admitted to the medical departments
(63%). The predominant comorbidity observed in males (25%), females (14%), and irrespective of sex (39%)
was diabetes mellitus followed by hypertension, which was observed in 30% of the total patients. It was
observed that men on average were taller (1.637 vs. 1.526 m) and heavier (66.367 vs. 56.881 kg) than women,
but their BMI (24.395 vs 24.455 kg/m2) was significantly lower (p < 0.01) than that of women. The prevalence
of comorbidities such as diabetes and hypertension in different socioeconomic classes is depicted in Figure
1.
2022 Mahadevan et al. Cureus 14(5): e24681. DOI 10.7759/cureus.24681 3 of 8
FIGURE 1: Prevalence of diabetes and hypertension in different
socioeconomic classes
The overall prevalence of diabetes and hypertension was found to be 39% and 30% respectively. The highest
prevalence of diabetes and hypertension was observed in Class 1. The anthropometric measurements
concerning socioeconomic classes in the patients selected for the study are presented in Table 2.
2022 Mahadevan et al. Cureus 14(5): e24681. DOI 10.7759/cureus.24681 4 of 8
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